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50 Cards in this Set

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Thymoma - Stage I
Thymoma - Stage I

Macroscopically completely encapsulated and microscopically no capsular invasion

5-year survival: 93%
Thymoma - Stage II
1 Macroscopic invasion into surrounding fatty tissue or mediastinal pleura
2 Microscopic invasion into sapsule

5-year survival: 86%
Thymoma - Stage III
Thymoma - Stage III

Macroscopic invasion into neighboring organ (pericardium, great vessels, or lung)

5-year survival: 70%
Thymoma - Stage IVA
Thymoma - Stage IVA

Pleural or pericardial dissemination

5-year survival: 50%
Thymoma - Stage IVB
Thymoma - Stage IVB

Lymphatic or hematogenous mets

5-year survival: 50%
Thymoma Treatment by Stage

I

II
Thymoma Treatment by Stage

I: Complete resection only

II: Complete resection then postop RT (45/25)
Thymoma Treatment by Stage

III

IV
Thymoma Treatment by Stage

III: Complete resection (if possible) then postop RT (50-54 Gy).
If inop initially, preop RT +/- chemo (doxorubicin or cisplatin); otherwise, def RT (54-60Gy).

IV: Induction combination chemo then RT +/- surgery
Thymoma - Five-year survival by stage

I

II

III

IV
Thymoma - Five-year survival by stage

I: 93%

II: 86%

III: 70%

IV: 50%
Thymoma - Follow-up
Thymoma - Follow-up

Late recurrences possible.
Most remain indolent and confined to thorax
Follow for life.
Thymoma

What % associated with myasthenia gravis (MG)?

What % of MG patients have thymoma?
Thymoma

What % associated with myasthenia gravis (MG)? 35-50%

What % of MG patients have thymoma? 15%
Thymus mass tumors
Thymus mass tumors

Lymphoma
Thymoma
Germ cell tumors
Carcinoid
Thymic carcinoma
Thymoma - Anterosuperior mediastinal tumors
Thymoma - Anterosuperior mediastinal tumors

Terrible lymphoma
Thyroid
Thymic tumors
Teratomas
Tracheal tumors
Thymoma - Middle mediastinal tumors
Thymoma - Middle mediastinal tumors

Lymphoma
Lung cancer
Heart tumors
Vascular tumors
Thymoma - Posterior mediastinal tumors
Thymoma - Posterior mediastinal tumors

Neurogenic tumors
Esophageal tumors
Thymoma - Associated abnormalities
Thymoma - Associated abnormalities
Myasthenia gravis - 35-50%
Red cell aplasia 5%
Hypogammaglobulinemia 5%
Thymoma

What is the main method by which thymoma spreads?
Thymoma

What is the main method by which thymoma spreads?

Local invasion
Thymoma

What is the diagnostic study of choice for thymoma?
Thymoma

What is the diagnostic study of choice for thymoma?

CT
- Usually found on chest x-ray
- MRI of no additional benefit
Thymoma

What area should be treated in the postop setting?
Thymoma

What area should be treated in the postop setting?

The entire area from which the thymoma arose (eg, posterior sternum or anterior chest wall if the tumor abutted those areas)
Thymoma

What studies should be included for staging?
Thymoma

CT
Labs
- AFP, HCG (to exclude GCT)
- Free T4, TSH (thyroid)
- CBC (red cell aplasia)
Thymoma

What is the name of the thymoma staging system?
Thymoma

What is the name of the thymoma staging system?

Masaoka
Thymoma - At presentation what percent of patients have

Stage I
Stage II
Stage III
Thymoma - At presentation what percent of patients have

Stage I: 40%
Stage II: 20%
Stage III: 40%
Thymoma - What is the treatment of choice?
Thymoma - What is the treatment of choice?

Resection. If the capsule is violated, there is a high propensity for local recurrence.

Any involved structures should be resected.
Protect the phrenic nerves.
Thymoma - What is the biopsy method of choice?
Thymoma - What is the biopsy method of choice?

Avoid incisional biopsy.
FNA is preferred to reduce risk of local recurrence.
Thymoma

Common preop chemotherapy regimens to reduce size?
Thymoma

Common preop chemotherapy regimens to reduce size?

CHOP
- Cyclophosphamide
- Doxorubicin
- Vincristine
- Prednisone
PAC
- Cisplatin
- Doxorubicin
- Cyclophosphamide
Cisplatin and etoposide (like SCLC)
Thymoma - Radiation technique
Thymoma - Radiation technique

- Entire thymus (or bed) and involved organs
- 1-cm margin
- Use preop CT to delineate preop tumor extent
- Use op note and path to identify adherent, invasive disease
- Stage II: 45Gy at 1.8 Gy/Fx
- Stage III: 50.4-54Gy at 1.8 Gy/Fx
- Gross residual disease: 60-65Gy based on DVH
Thymoma - What is the main role of chemotherapy in thymoma?
Thymoma

What is the main role of chemotherapy in thymoma?

The main indication for chemotherapy is as preop therapy in an attempt to render a tumor resectable or amenable to radical RT.
Thymoma - Initial series
Thymoma - Initial series

1928-1972 Invasive thymoma
Batata from MSKCC and Marks from South Carolina
Surgery or surgery plus RT
5yr DFS
- 0/8 for surgery alone
- 6/28 for surgery + RT
All who had incomplete resection and RT < 40 Gy had recurrence.
Thymoma - Adj RT
Thymoma - Adj RT
Curran Stage I disease
- Surgery alone or gross total resection with RT led to 5yr local control 100%
- Gross total resection without RT: 53% local control
- Subtotal resection + RT: 50% local control
Stage II/III: GTR
+RT: 95% local control
-RT: 72% local control
Thymoma 2007 InService

The 5-year survival for patients who have undegone RT for inoperative stage III invasive thymoma is approximately
A 20%
B 50%
C 70%
D 90%
Thymoma 2007 InService

The 5-year survival for patients who have undegone RT for inoperative stage III invasive thymoma is approximately

B 50%
Thymoma 2007 InService

Which of the following types of cancer is most commonly associated with myasthenia gravis?
A Small cell lung cancer
B Non-small cell lung cancer
C Mesothelioma
D Thymoma
Thymoma 2007 InService

Which of the following types of cancer is most commonly associated with myasthenia gravis?

D Thymoma
Thymoma 2006 InService

Which of the following types of cells comprise the neoplastic cells of thymoma?
A Immature T-cells
B Mature T-cells
C Epithelial cells
D Dendritic reticular cells
Thymoma 2006 InService

Which of the following types of cells comprise the neoplastic cells of thymoma?

C Epithelial cells
Thymoma 2006 InServce

Which of the following structures is NOT part of the boundaries of the mediastinum?
A Thoracic inlet
B Pericardium
C Diaphragm
D Parietal pleura
Thymoma 2006 InServce

Which of the following structures is NOT part of the boundaries of the mediastinum?

B Pericardium
Thymoma 2006 InService

Which of the following neoplasms is NOT commonly found in the anterior mediastinum?
A Lymphomas
B Thymic tumors
C Germinal cell tumors
D Neurogenic tumors
Thymoma 2006 InService

Which of the following neoplasms is NOT commonly found in the anterior mediastinum?

D Neurogenic tumors
Thymoma - 2006 InService

Which of the following structures is NOT found in the middle mediastinum?
A Heart
B Trachea
C Lymph nodes
D Esophagus
Thymoma - 2006 InService

Which of the following structures is NOT found in the middle mediastinum?

D Esophagus
Thymoma - 2006 InService

According to the Masaoka thymoma staging system, a lesion invading into surrounding mediastinal pleura would be classified as which of the following stages?
A I
B II
C III
D IV
Thymoma - 2006 InService

According to the Masaoka thymoma staging system, a lesion invading into surrounding mediastinal pleura would be classified as which of the following stages?

B II
Thymoma - 2006 InService

Which of the following statements about the management of thymomas is FALSE?
A Surgical excision in the primary treatment of choice.
B RT is useful as adj therapy.
C Thymomas are usually radioresponsive.
D Chemotherapy has no role.
Thymoma - 2006 InService

Which of the following statements about the management of thymomas is FALSE?

D Chemotherapy has no role.
Thymoma - InService 2006

Which of the following adverse effects is NOT reported after RT for thymoma?
A Pericarditis
B Pneumonitis
C Esophagitis
D Xerostomia
Thymoma - InService 2006

Which of the following adverse effects is NOT reported after RT for thymoma?

D Xerostomia
Thymoma - 2006 InService

Which of the following structures is NOT found in the middle mediastinum?
A Heart
B Trachea
C Lymph nodes
D Esophagus
Thymoma - 2006 InService

Which of the following structures is NOT found in the middle mediastinum?

D Esophagus
Thymoma - 2006 InService

According to the Masaoka thymoma staging system, a lesion invading into surrounding mediastinal pleura would be classified as which of the following stages?
A I
B II
C III
D IV
Thymoma - 2006 InService

According to the Masaoka thymoma staging system, a lesion invading into surrounding mediastinal pleura would be classified as which of the following stages?

B II
Thymoma - 2006 InService

Which of the following statements about the management of thymomas is FALSE?
A Surgical excision in the primary treatment of choice.
B RT is useful as adj therapy.
C Thymomas are usually radioresponsive.
D Chemotherapy has no role.
Thymoma - 2006 InService

Which of the following statements about the management of thymomas is FALSE?

D Chemotherapy has no role.
Thymoma - InService 2006

Which of the following adverse effects is NOT reported after RT for thymoma?
A Pericarditis
B Pneumonitis
C Esophagitis
D Xerostomia
Thymoma - InService 2006

Which of the following adverse effects is NOT reported after RT for thymoma?

D Xerostomia
Thymoma - Describe the anterior (anterosuperior)mediastinum.
Thymoma - Describe the anterosuperior mediastinum.

Anterior to the pericardium
Contains
- Thymus
- Extrapericardial aorta
- Great veins
- Lymphatic tissue
Thymoma - Describe the middle mediastinum.
Thymoma - Describe the middle mediastinum.

Ant: Pericardium
Post: Pericardial reflection
Inf: Diaphragm
Sup: Thoracic inlet
Contains
- Heart
- Intrapericardial great vessels
- Pericardium
- Trachea
Thymoma - Describe the posterior mediastinum.
Thymoma - Describe the posterior mediastinum.

Ant: Post pericardial reflection
Post: Posterior vert body border
Sup: First rib
Inf: Diaphragm
Contains
- Esophagus
- Vagus nerves
- Thoracic duct
- Sympathetic chain
- Azygous venous system
Thymoma - What is the standard surgical approach?
Thymoma - What is the standard surgical approach?

Chamberlain procedure for limited anterior mediastinotomy
Thymoma - What is the origin of the neoplastic cells?
Thymoma - What is the origin of the neoplastic cells?

Originate from epithelial cells within the thymus that are cytologically benign but biologically aggressive
Thymoma - What is the five-year survival rate?
Thymoma - What is the five-year survival rate?

~65%
Thymoma - What is the most important prognostic factors?
Thymoma - What is the most important prognostic factor?

Disease stage and extent of resection
(Zhu IJROBP 2004;60:1113)
Thymoma - Does myasthenia gravis manifest in patients with thymic carcinoma?
Thymoma - Does myasthenia gravis manifest in patients with thymic carcinoma?

Not unless it is well differentiated thymic carcinoma.
Thymoma - Normal tissue tolerances

Spinal cord
Lung
Heart
Esophagus
Thymoma - Normal tissue tolerances

Spinal cord < 45 Gy
Lung V20 < 30%
Heart V25-40 < 30%
Esophagus < 60 Gy (V50 < 30%)